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UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM(Page i Qf i) Type of Action 5 Installation Inspection ❑Repair Inspection ❑36 Month Inspection I. FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment Inspection Business Name(Same as Facility Name or DBA-Doing Business As) Business Site Address City ZIP Code i UU i V ('7104 kd MI ''5-2 c� 11. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection(Print as shown on the ICC Certification.) Phone# VAV C t, k I1Clk1 d h l_CD91(041'1 �,� Contractor i Tank Tester License* ICC Certification# ICC Certification Expiration Date Overfill Prevention Equipment Inspection Training and Certifications(List applicable,certifications.) 0,,9 vt/ /vs-7-v /,4'W0/J /Vis/ .C-if- /5U7eG?6'/7vti III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method 5ZManufacturer Guidelln, s(Specify): Used: e� r N - T- N Gr -/Zw C e /NS cr T7 Uri)S ❑Industry Code or Engineering Standard(Specify): ❑Engineered Method(Specify): Attach the inspection procedures and ail documentation required to determine the results. #of Attached Pages TANK ID:(By tank number, stored product, etc.) ©k E rj t-. (r What is the tank Inside diameter?(inches) Cr(,f I Is the fill piping secondarily contained? ❑Yes Z No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No Is the vent piping secondarily contained? ❑Yes -No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No Overfill Prevention Equipment Manufacturer(s) What is ft overfill prevention equipment response Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow when activated? Restricts Flow ❑Restricts Flow ❑Restricts Flow ❑Restricts Flow (Check all that apply.) ❑AIV Alarm ❑AN Alarm ❑AN Alarm ❑AN Alarm Are flow restrictors installed on vent piping? ❑Yes No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No At what level in the tank is the overfill prevention set to activate?(Inches from bottom of tank.) gj i What is the percent capacity of the tank at which the overfill prevention equipment activates? —1 Is the overfill prevention in proper operating condition Cit Yes ❑Yes ❑Yes ❑Yes to respond when the substance reaches the 1CC3appropriate level? No(Specify/y in V.) ❑No(Specify in V.) No(Spedfy in V.) ❑No(Specify�in V.) IV. SUMMARY OF INSPECTION RESULTS Overfill Prevention inspection Results Pass ❑Fail ❑Pass E3 Fail 1 ❑Pass C]Fall E3 Pass ❑Fail V. COMMENTS Any items marked"Fait'must be explained in this section. Any additional comments 9ftoobsprqv4dedhere. VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION 1 hereby certify that the overfill prevention equipment was inspected in accordaniie' rViik bf.of Regulations,Title 23, Division 3,Chapter 16, Section 2637.2 and all Information contained herein Is accurate. ;- UST Service Technician Signature ales,acct I copes of this page may ff this facility has more components than this form co Code! Colo,AN=Atxiibb Visual CERS=CaAkxr4a E,*On nWW Repod5 System,r ID=iderrtlllratirinn, - Storage Ter*.ICC=hiemational